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the bmj | 9 January 2016 1

NEWS ONLINE

• Wider group of health professionals should be located in emergency departments

• Drug companies to pay $39.5m in OxyContin and Risperdal cases

• Government’s U turn on custodial healthcare will endanger vulnerable people, says BMA

GPs to convene crisis summitThe chair of the BMA’s General Practitioners Committee has warned the government that the future sustainability of UK general practice is “in serious question,” ahead of a crisis summit later this month.

Chaand Nagpaul said that the first special meeting of local medical committees (the statutory bodies that represent GPs locally) in 13 years—due to take place on 30 January—highlighted the severity of the current crisis in general practice and would bring to the fore “an issue that can no longer be ignored by politicians.”

The meeting has been organised by the BMA in response to growing concern among members of local medical committees that rising demand from patients, stretched resources, and over-regulation were harming the care of patients and causing widespread burnout in the profession, leading to ongoing problems with recruitment and retention.

GPs will debate a range of motions to decide what action to take to deliver “a safe and sustainable service” in the future, including the possibility of taking industrial action against the government.

Nagpaul told The BMJ, “We are now at a juncture where general practice’s future

sustainability is in serious question, and the ability of GPs to continue with their current workload and current pressures is unsustainable. This conference has been called because we are in a desperate situation with regards to general practice.”

Nagpaul added, “The conference is bringing to the fore an issue that can no longer be ignored by politicians. But it is also about ensuring clear action is taken to enable general practice to get back on its feet.”

Peter Holden, a member of Derbyshire Local Medical Committee and a former negotiator on the BMA General Practitioners Committee, has proposed a motion warning the government that industrial action from GPs was “on the cards” unless the government acted to support the beleaguered primary care system.

Holden told The BMJ, “The government must not think that whatever happens with the juniors isn’t on the cards with the GPs. We have to have a restoration of the GP expenses system—also we have to make [general practice] attractive for the young ones to want to come in.”Gareth Iacobucci, The BMJCite this as: BMJ 2016;352:i14Find this at: http://dx.doi.org/10.1136/bmj.i14

Chaand Nagpaul said the current crisis in general practice “can no longer be ignored by politicians”

SEVEN DAYS IN

Saturday 2nd BMJ appeal update Readers have so far raised £15 000 for Doctors of the World in The BMJ ’s Christmas appeal, which runs until the end of January.

Councils call for calorie count on alcohol labels The Local Government Association, which represents

around 400 councils in England and Wales, said that the effect of hidden calories in alcohol is contributing to the UK’s obesity crisis. Its demand echoed that of the Royal Society for Public Health, which has called for calorie labels to be put in place, as well as MEPs’ calls in 2015 for calorie labels to

be put on all alcoholic drinks in a vote at the European Parliament, although that vote is not binding.

Sunday 3rd Government gives go ahead to e-cigarettes on NHS The Department of Health confirmed that e-Voke, an e-cigarette that has been given a UK licence as a smoking

cessation aid, will be allowed to be prescribed on the NHS when it becomes available. The Royal College of General Practitioners warned that GPs could be overwhelmed with requests for the device, which is made by British American Tobacco. Tim Ballard, vice chair of the royal college, said that he would like to see e-cigarettes assessed by the National Institute for Health and Care Excellence. (See also: European watchdog is failing to hold tobacco industry to account over smuggling, at doi:10.1136/bmj.h6973.)

Monday 4th Campaign launches to reduce children’s sugar intake Public Health England encouraged parents to take control of their children’s sugar consumption with a new Sugar Smart app that scans barcodes of products to show the amount of sugar they contain in sugar cubes and grams. The campaign followed

research showing that children aged 4 to 10 consume over 5500

sugar cubes a year, equal to around

22 kg—the average weight of a 5 year old. The recommended daily maximum added sugar intake

is 19 g for 4 to 6 year olds (five sugar cubes),

24 g for 7 to 10 year olds (six cubes), and 30 g for 11 year olds (seven cubes).

Infertility treatment is not associated with developmental delays A prospective cohort study of 4824 mothers to 5841 children, including 1830 conceived with infertility treatment and 2074 twins, found that infertility treatment was not associated with the risk of children

failing any of five developmental

domains up to age 3.

The areas covered were fine motor skills, gross motor skills, communication, personal-social functioning, and problem solving ability. (See The BMJ ’s full story at doi:10.1136/bmj.h7028.)

Midlands hospital appoints humanist “pastoral carer” Leicester Hospitals appointed a humanist pastoral carer to support patients, families, and staff with non-religious beliefs. The hospital group is thought to be the first to make such an appointment. Jane Flint, whose part time post is funded by the Leicester Hospitals Charity, has qualifications in psychotherapy, adult education, and counselling and is accredited in non-religious pastoral support by the British Humanist Association, with which she is also an accredited funeral celebrant. (Full BMJ story doi:10.1136/bmj.h7023.)

Tuesday 5th Adult cancer

survivors are at risk of cardiac abnormalities A study of 1853 adults who received either anthracycline chemotherapy or cardiac directed radiation therapy for

Junior doctors are set to take three days of industrial action, aft er negotiations between the association and the government over the terms of the junior doctor contract broke down on Monday, 4 January, the BMA has said.

As The BMJ went to press the association announced that the action would take place in January and February, aft er the government failed to meet junior doctors’ concerns over changes to their contract. It said that the government did not recognise the need for robust contractual safeguards for safe working or the need for proper recognition of unsocial hours worked by junior doctors.

The BMA said that the fi rst day of industrial action would be Tuesday 12 January, when for 24 hours junior doctors will provide emergency cover only.

It said that, unless junior doctors’ concerns were dealt with, the action would be followed by a second, 48 hour period of industrial action, beginning on 26 January. This would be followed by a day of strike action on 10 February, which would see a full withdrawal of junior doctors’ labour between 8 am and 5 pm, the BMA said.

In November 98% of junior doctors in a ballot voted in favour of industrial action.

Junior doctors will strike next week

Abi Rimmer BMJ Careers Cite this as: BMJ 2016;352:i43 LYN

CHPI

CS/A

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2 9 January 2016 | the bmj

Johann Malawana, chair of the BMA’s Junior Doctors Committee

MEDICINEa childhood cancer found that cardiomyopathy was present in 7.4%, coronary artery disease in 3.8%, valvular regurgitation or stenosis in 28%, and conduction or rhythm abnormalities in 4.4%. Often the survivors were asymptomatic, with cardiac abnormalities occurring at a younger age than usual, suggesting that research into screening this group of patients is needed, said the researchers in the Annals of Internal Medicine. (Full BMJ story doi:10.1136/bmj.h7026.)

Wednesday 6thAntibiotic reduces malaria risk in adults taking antiretroviral therapy In malaria endemic regions, people with HIV infection who are treated with antiretroviral therapy do better if they also take the antibiotic co-trimoxazole, a trial in Kenya published in PLoS Medicine showed. The World Health Organization recommended prophylactic use of co-trimoxazole in 2006, but that guidance predated the widespread use of antiretroviral therapy, so it has not been clear whether it remains appropriate. The trial, which showed that mortality and morbidity were higher among those in whom co-trimoxazole was discontinued, backed the continued use of the WHO guidance. (Full BMJ story doi:10.1136/bmj.i5.)

Oral antifungal drug is linked to spontaneous abortionsUse of the oral antifungal drug fluconazole during pregnancy was associated with a significantly higher risk of spontaneous abortion in an analysis of 1.4 million pregnancies in Denmark published in JAMA. However, the researchers noted that the severity of vaginal candidiasis might be a confounding factor and that severe vaginal

Candida infection alone could result in pregnancy loss. They concluded, “Until more data on the association are available, cautious prescribing of fluconazole in pregnancy may be advisable.” (Full BMJ story doi:10.1136/bmj.h7029.)

Thursday 7th

Disabled children are at risk after initial unsubstantiated referral for neglect Children with disabilities who have an initial unsubstantiated referral for neglect are at increased risk of being maltreated subsequently, a research letter published in JAMA claimed. A total of 12 610 children with disabilities and 476 566 children without disabilities who had first time unsubstantiated referrals for neglect in 2008 were followed up for four years. Children with disabilities were more likely to be re-referred to child protective services than those without (45% versus 36%) and were more likely to experience substantiated maltreatment (16% versus 10%). (Full BMJ story doi:10.1136/bmj.h7031.)Cite this as: BMJ 2016;352:i9Find this at: http://dx.doi.org/10.1136/bmj.i9

E-CIGSE-Voke is the first e-cigarette to be approved as an

aid to stop smoking

I’M FEELING A BIT DISTRAIT. IS THERE A PILL FOR IT?Try mindfulness. It’s the antidote to stress, distilled from the wisdom of ancient Buddhism and brought bang up to date to ease the travails of the modern world.

IT SOUNDS A BIT FLAKY TO MEIt’s easy to scoff. But plenty of people find it helpful, and it’s inching towards making the transition from pop psychology to clinical acceptance.

SUM IT UP IN A SENTENCEMindfulness means paying attention in a particular way—on purpose, in the present moment, and non-judgmentally, says Jon Kabat-Zinn, a student of Buddhist meditation who has been promoting the idea with growing success since 1979. The idea is to use meditation techniques to focus your mind on the here and now instead of having unhelpful thoughts about the past or the future.

BUDDHISM LITE, THEN?That’s what critics say, accusing Kabat-Zinn’s successors of marketing “McMindfulness,” ripped from its context and lacking soul.

NEVER MIND THE PURISTS, DOES IT WORK?A bit. A head to head trial designed to see which treatment was most effective in preventing relapse into depression showed that mindfulness techniques did as well but no better than antidepressants. Neither was especially effective. And a meta-analysis found it moderately to largely effective

for a variety of psychological problems, including anxiety, depression, and stress. But study results varied widely, and attrition rates were high, so these findings may be overstated, in the view of the University of York’s Centre for Reviews and Dissemination.

IS IT CHEAP, AND IS IT SAFE?A course of eight weekly sessions in Oxford costs £350. And side

effects, such as re-emergence of traumatic memories or becoming “depersonalised,” can occur. Their frequency and severity are contested.

Nigel Hawkes, freelance journalist, LondonCite this as: BMJ 2015;351:h6960

Ж EDITORIALS, p 9

SIXTY SECONDS ON . . . MINDFULNESS



“I’m sure more improbable things have happened, but I can’t think of any,” said Eddie Chaloner, a member of the Lewisham & Greenwich NHS Choir, which hit the top of the singles chart this Christmas with the song “A Bridge Over You.”

The song clinched the number one slot from Justin Bieber on Christmas Day, outselling the Canadian singer’s song “Love Yourself” by 30 000 copies (127 000 versus 97 000). In the first chart of 2016 the song had dropped to number 29.

The choir, which includes all types of NHS staff, was runner up on Gareth Malone’s BBC 2 television show Sing While You Work in 2012.

“A Bridge Over You” was arranged by choir masters who took over when Malone left. Released in 2013 to celebrate the NHS, the song did reasonably well in a specialist chart. But it wasn’t until Harriet Nerva, a junior doctor at Hinchingbrooke Hospital in Cambridgeshire and nothing to do with the choir, stumbled across it after a difficult shift that the song really took off. Nerva made it her mission to make the song 2015’s Christmas number one hit. With help from Katie Rogerson, a paediatrician and a choir member, and Joe Blunden, an NHS communications manager, she launched a strategic social media campaign and did just that.

The song blends Simon and Garfunkel’s “Bridge Over Troubled Water” and Coldplay’s “Fix You.”

“It encapsulates what we feel about what we do,” said Chidi Ejimofo, a consultant in emergency medicine at University Hospital Lewisham and one of the song’s star soloists. “There is real buzz among NHS staff. It feels like a real affirmation about how people feel about the NHS.”

That the NHS choir sits alongside other Christmas chart toppers such as The Beatles, Spice Girls, Band Aid, and Elvis Presley, had yet to sink in, he said.

The choir chose to donate all sales from the song to charities, in particular Carers UK and the mental health charity Mind, because “the work that they do takes a lot of pressure from the NHS,” said Chidi. Some smaller charities will also be benefiting in the New Year.

Zoe Davies, another soloist on the song, told The BMJ, “It is a difficult time for the NHS at the moment. From a junior doctor’s point of view it [the NHS crisis] was at the top of the agenda.

“People like the song, and people want to show their support for the NHS and free healthcare. It shows the government that people truly support the NHS.”

Although she now works as a medical registrar at St Thomas’s Hospital in London, Davies continues to sing in the choir.

She said that the support for the campaign had been “completely overwhelming and positive.” Chidi added: “It will be easier to recruit new choir members.”Zosia Kmietowicz, The BMJ Cite this as: BMJ 2016;352:h7022Find this at: http://dx.doi.org/10.1136/bmj.h7022

NHS choir’s Christmas hit puts health service in spotlight


“It shows the government that people truly support the NHS” – Zoe Davies

CHID

I EJIM

OFO

Some members of the the Lewisham & Greenwich NHS Choir (left to right), Caroline Smith, children’s community physiotherapist; Petrina Pottinger, IT systems manager; Suzanne Bennet (behind),

speech and language therapist; Katie Rogerson, paediatrician; Zoe Davies, registrar; Chidi Ejimofo, consultant in emergency medicine; Katie Evans, doctor, and Caroline Duffy, theatre nurse


Support from governmentDamoiseaux says that wherever it can the Dutch government supports GPs because it sees primary care as its ally in the effort to save costs in secondary care. Whereas, McCartney says, in the UK the current government’s approach to the NHS as a whole has united GPs and specialists in opposition to the government and to specific government policies amid a sense of misdirection.

Damoiseaux explains that in some ways the Dutch insurance based system gives Dutch GPs greater power to negotiate between insurance companies and the government for what they want.

“Insurance companies are private companies,” he says. “There are several—five or six—in the Netherlands so there is a certain room to negotiate about things. Sometimes the union even goes back to the minister and says, ‘We just don’t want to do it like this or we will not do the other things we’ve planned together.’”

Damoiseaux describes a grass roots revolt this year by Dutch GPs, who refused to cooperate when insurance companies attempted to impose more box ticking and targets. By contrast, McCartney says, British GPs are frustrated that the Quality and Outcomes Framework has reduced consultations to a box ticking process.

“I think a lot of GP energy has been expended doing the wrong

stuff for too long,” she says, referring to GPs becoming involved in commissioning hospital services under changes introduced in 2004. That shift was stressful for a lot of GPs and took them away from their patients. “I think that changed a lot of doctors’ perceptions of what it is that GPs do or don’t do.”

Image of the professionMcCartney also feels strongly that in the UK, the media’s portrayal of general practice, combined with attitudes towards the profession in some medical schools, discourages some students before they have any direct experience of the job.

“I think a lot of doctors coming through (medical school) will have a look at what people think about general practitioners and won’t like what they hear,” says McCartney. “There are

some universities that are popular breeding grounds for GPs and

other universities that hardly seem to produce any. Some senior doctors think that’s

because health professionals [in those universities] speak down

about GPs sometimes.”The Royal College of General

Practitioners is currently running a campaign, “There’s nothing general about general practice,” to try to change negative attitudes. But, says McCartney, there has long been too much public focus on the problems GPs face rather than the joys of the job.

Damoiseaux says that, in contrast, the image of the profession is strong in the Netherlands. Although many medical students want to be surgeons or enter other specialties, all medical schools in the Netherlands seem to give students positive insights into general practice and the media do not overemphasise what’s wrong with the profession.

SalariesMcCartney also says uncertainty for GPs over their salaries is demoralising working GPs and putting off young doctors. Whereas Dutch GPs’ salaries have remained stable for years, in the UK they have been falling for the past few years. GPs were given a large rise because they were earning far less than specialists, McCartney says, but that was then seen as being too much and since then it has been declining. “To a certain extent that gives instability because you don’t quite know what’s going to happen next,” says McCartney. “I would rather just know how much money I had than worry that it is going up and down all the time.”Sophie Arie is a freelance journalist, London [email protected].

Cite this as: BMJ 2015;351:h6870Find this at: http://dx.doi.org/10.1136/bmj.h6870

“Our guidelines in general are given to us from on high. They are not really written for GPs” Margaret McCartney, Glasgow GP

bmj.com/podcasts Ж When Margaret met Roger:

listen to the podcast online


Why are Dutch GPs so much happier?General practice is similar in the Netherlands and the UK yet it appeals far more to young Dutch doctors than to their British counterparts. In collaboration with the Dutch medical journal Nederlands Tijdschrift voor Geneeskunde, Roger Damoiseaux, professor of general practice in Utrecht, and Margaret McCartney, Glasgow GP and The BMJ columnist, met to try to work out why. Sophie Arie reports

“In the Netherlands GPs have a very strong position in healthcare” Roger Damoiseaux, professor of general practice, Utrecht

In many ways, the daily work of a general practitioner in the Netherlands and the United Kingdom is similar. Working hours, pay, and time spent

with patients are comparable (table). Increasing numbers of GPs work part time in both countries, and they struggle with the same pressures of caring for an ageing population amid constant cuts to welfare, social services, and healthcare.

Yet the job is respected and popular in the Netherlands, with 1250 young medical graduates competing for 750 trainee posts last year, whereas 451 GP trainee posts were unfilled in the UK in 2014. In a wide ranging discussion with Roger Damoiseaux, professor of general practice at Utrecht University, Glasgow GP Margaret McCartney says the public image of the profession in the UK and the policies of the current government are part of the reason. Damoiseaux points to several key strengths of the profession in the Netherlands that may explain why it is stronger both politically and in terms of status than in the UK.

primary care. It started with diabetes and now has guidelines on around 100 conditions.

“We make them ourselves. They are supported by all GPs. And it’s easy to say to specialists, ‘This is what we do,’” says Damoiseaux.

By contrast, guidelines in the UK are set down by the National Institute for Health and Care Excellence and cover both primary and hospital care.

“Our guidelines in general are given to us from on high. They are not really written for GPs in the front line dealing with people with undifferentiated symptoms, most of whom will not have the diagnosis that the guidelines have been written about,” says McCartney.

“I think this is key to the way primary care sees itself and the way others see it: not valid enough to do our own research and our own work with our own stipulations of what’s good and what isn’t. We have terrible trouble persuading some people sometimes that not following some guidelines is actually very much in the best interest of the patient.”

How general practice compares in the UK and the Netherlands UK Netherlands

Average income:Full time GP partnerSalaried GP

£103 000 (€139 000)£56 800 (€75 000)

£92 000 (€127 000)£48 000-£62 000 (€66 000-€88 000) plus extra for night duties

Change in incomes in recent years Income has fallen by 11% since 2008 Stayed same since 2008Proportion of GPs who are partners 72% (down from over 90% in 2000) 82% (down from 90% in 1995)WorkloadFull time partnerFull time salaried GPAverage consultationAverage No of patients per dayChange in consultation rateOvernight care

60 hours/week50 hours/week10 minutes4024% increase since 1998GPs can opt in or out

60 hours/week50 hours/week10 minutes40No change in past 5 yearsAll GPs provide overnight care twice a month

GP training/qualifying 3 years. Training and trainee salary paid by government

3 years. Training and trainee salary paid by government

Popularity of the job 451 GP trainee vacancies unfilled after 2 recruitment rounds

1200 applicants for 750 trainee vacancies

Male:female ratio Over 50% female since 2013 45% female in 2014

Information given here is based on data from 2014 unless otherwise stated. The UK information comes from the Royal College of General Practitioners, BMA, and Health and Social Care Information Centre. The Dutch information comes from the Dutch Healthcare Authority and the Netherlands Institute for Health Services Research (NIVEL).

Strong union“In the Netherlands GPs have a very strong position in healthcare,” says Damoiseaux. The National Association of General Practitioners (LVH) represents 80% of all GPs.

“They take care of the salaries, negotiations with the minister, and also how we organise general practice. So it’s a very strong group of professionals and I think that is seen by the public and also by the students,” he says.

The strength of the GPs’ union to negotiate with government, Damoiseaux believes, partly explains why Dutch students are attracted to the profession. In the UK, GPs have no union of their own. Some 31 985 of the 40 584 GPs (79%) are members of the British Medical Association, the trade union for all UK doctors.

Respected guidelinesAnother key difference Damoiseaux points out is that the Dutch College of General Practitioners has, since 1989, drawn up its own guidelines on how to treat specific conditions in


Communication about cancer screening is dodgy: benefits are overstated and harms downplayed. Several techniques of

persuasion are used. These include using the term “prevention” instead of “early detection,” thereby wrongly suggesting that screening reduces the odds of getting cancer. Reductions in relative, rather than absolute, risk are reported, which wrongly indicate that benefits are large.1 And reporting increases in 5 year survival rates wrongly implies that these correlate with falls in mortality.2 Prasad and colleagues put their finger on another misleading practice: claiming that screening “saves lives” despite the lack of proof that overall mortality is decreased.3

Simple, and wrongA fall in cancer specific mortality alone cannot prove that lives are saved—the cause of death may be systematically misclassified or screening and subsequent cancer treatment may increase deaths from other causes, most likely as a consequence of overdiagnosis and overtreatment.3 4 To prove that screening saves lives one needs to find a difference in overall mortality. Yet detecting such a difference, if it exists, with reasonable statistical power in the general population would require studies with millions of participants. Can we get around this dilemma?

Prasad and colleagues propose reporting overall mortality in addition to cancer specific mortality and, if there is no difference in overall mortality, to stop claiming that screening saves lives. I agree but would like to add some additional points to their call for more honesty.

Firstly, reporting cancer specific and overall mortality is essential because not only do patients lack an understanding of what constitutes evidence for “saving lives,” but many doctors do too. In a US sample, 47%

of 412 physicians wrongly thought that the detection of more cancers in screened than in unscreened populations proved that screening saves lives. And 76% wrongly thought that if people with screen detected cancers had better 5 year survival rates than those with symptom detected cancers, then screening saved lives.5 Given such widespread confusion, it can be helpful to report both cancer specific mortality and overall mortality.

Secondly, overall cancer mortality should also be reported, where possible. If there is a reduction in cancer-specific mortality that does not result in deaths from other causes or from misclassification, then this reduction should be reflected in a fall in overall cancer mortality (which includes cancer-specific mortality). Because the base rate of overall cancer mortality is lower than that of overall mortality, tests have a higher power to detect such a difference. Overall cancer mortality can control for systematic errors in classifying cancer causes of death.3 It cannot, however, capture non-cancer deaths caused by treatment, which is a limitation.

Tools for informed choicePrasad and colleagues write, “As long as we are unsure of the mortality

benefits of screening, we cannot provide people with the information required to make an informed choice. We must be honest about this uncertainty.” But even if this uncertainty cannot be removed, we can provide people with useful tools, such as fact boxes (figure ).6 We use a fact box on mammography screening that reports all three measures of mortality, based on a Cochrane review.7 It clearly shows that cancer specific mortality is reduced by 1 in 1000 women and that this difference is not reflected in overall cancer deaths nor in overall mortality. The harms are specified numerically so that an informed decision about screening is possible. Every article and pamphlet should provide a fact box summary to facilitate informed decisions.

Rather than pouring resources into “megatrials” with a small chance of detecting a minimal overall mortality reduction, at the additional cost of harming large numbers of patients, we should invest in transparent information in the first place. It is time to change communication about cancer screening from dodgy persuasion into something straightforward.Cite this as: BMJ 2016;352:h6967Find this at: http://dx.doi.org/10.1136/bmj.h6967

Ж ANALYSIS, p 22

EDITORIAL

Full disclosure about cancer screeningTime to change communication from dodgy persuasion to something straightforward

Source: [1] Gøtzsche, PC, Jorgensen, KJ (2013). Cochrane database of systematic reviews (1): CD001877.pub5

Bene�ts How many women died from breast cancer? How many women died from all types of cancer? How many women died from any cause? Harms How many women without cancer experienced false alarms or biopsies? How many women with non-progressive cancer had unnecessary partial or complete breast removal?

Mammography screening may reduce the number of women who die from breast cancer, but that does not mean that lives are saved: no reduction has been shown for overall mortality and overall cancer deaths (including breast cancer). Among all women taking part in screening, some women will be overdiagnosed with non-progressive cancer and unnecessarily treatedNumbers for women aged 50 years or older who did or did not participate in screening for about 10 years

1000 womenwithout screening

52184

-

-

1000 womenwith screening

42184

50-200

2-10

Breast cancer early detectionby mammography

Gerd Gigerenzer director, Harding Center for Risk Literacy and Center for Adaptive Behavior and Cognition, Max Planck Institute for Human Development, Berlin, Germany [email protected]

Fact box on mammography screening for breast cancer

Every article and pamphlet should provide a fact box summary to facilitate informed decisions


EDITORIAL

Does mindfulness work?Reasonably convincing evidence in depression and anxiety

Mindfulness has been defined as the process of paying attention to the present moment

in a non-judgmental manner.1 In the early stages of mindfulness training, awareness of breathing is typically used as an attentional anchor to regulate ruminative thinking,2 but mindfulness encompasses much more than observing the breath. It derives from Buddhist practice and has been the subject of empirical investigation since the late 1970s, with over 700 scientific papers on mindfulness published in 2014.3

Evidence is most convincing for its use in the treatment of depression and anxiety. Meta-analyses assessing the efficacy of mindfulness in these two disorders have typically reported effect sizes in the moderate-strong to strong range (Cohen’s d ≥ 0.5).4 5 However, some of the studies included in these meta-analyses have failed to control for a placebo effect, so it is unsurprising that meta-analyses with more stringent inclusion criteria report more modest outcomes.

This time with active controlFor example, a recent meta-analysis of 36 randomised controlled trials of mindfulness based stress reduction, mindfulness based cognitive therapy, and other mindfulness based interventions—each with an active control— reported small to moderate effect sizes (d=0.3-0.38) in the treatment of depression or anxiety after eight weeks of mindfulness training, with a reduction in effect size

(d=0.22-0.23) at three to six months’ follow-up.6 Although these outcomes are more modest, they are comparable with results that would be expected from treatment with antidepressants in a primary care population, but without the associated toxicity.6

Consistent with these findings, the National Institute for Health and Care Excellence and the American Psychiatric Association advocate mindfulness based cognitive therapy for recurrent depression in adults.7 8 Some evidence suggests that mindfulness based interventions may have a role in treating other psychiatric conditions,9 but there is insufficient evidence from robustly designed trials to support its use for conditions other than depression and anxiety.

Evidence from randomised trials suggests that mindfulness based interventions (particularly mindfulness based stress reduction and cognitive therapy) are mildly to moderately efficacious in treating chronic pain (d=0.33),6 with possible applications for treating pain related disorders such as fibromyalgia.11 However, it is unclear whether mindfulness reduces the frequency and intensity of pain or simply improves patients’ ability to cope.11

Unanswered questionsVarious methodological problems limit the overall strength of the evidence on the efficacy of mindfulness. In particular, findings may be influenced by a form of “popularity effect”: participants may believe that they are receiving a “fashionable” or proved psychotherapeutic technique.9 This is a difficult confounding variable to control for because it is almost impossible to blind patients from the fact they are using mindfulness techniques.

We also need greater clarity on whether positive outcomes are maintained over years, rather than just months,2 9 whether mindfulness interventions have any adverse effects,

Edo Shonin, research director [email protected] William Van Gordon, principal investigator, Psychology Division, Nottingham Trent University, Nottinghamshire NG1 4BU, UK; and Awake to Wisdom Centre for Meditation and Mindfulness Research, Nottingham, UK Mark D Griffiths, professor, Psychology Division, Nottingham Trent University, Nottinghamshire NG1 4BU, UK

and the validity of the traditional view among contemplative traditions that sustainable improvements to health and wellbeing require daily mindfulness practice over many years.9

Furthermore, evidence is required to determine whether mindfulness in general or specific interventional approaches is most effective for a given illness. Numerous interventions have been formulated with considerable variation in factors such as total participant-facilitator contact hours (including whether there is one-to-one contact), quantity and duration of guided mindfulness exercises, use of non-mindfulness psychotherapeutic techniques, emphasis on self practice (typically supported by a CD of guided mindfulness exercises), and use of other meditation techniques (such as yoga).2

Interventions also vary in how they define and operationalise mindfulness.12 Substantial variations in design and pedagogic approach make it difficult to generalise findings across the full spectrum of interventions.

Evidence is growing that mindfulness is effective in increasing perceptual distance from distressing psychological and somatic stimuli and that it leads to functional neuroplastic changes in the brain.13 However, the “fashionable” status of mindfulness among both the general public and the scientific community may have overshadowed the need to examine important methodological and operational issues concerning its efficacy.Cite this as: BMJ 2015;351:h6919Find this at: http://dx.doi.org/10.1136/bmj.h6919

Comparable results to treatment with antidepressants in a primary care population

Ж Personal View: Use hand cleaning to prompt mindfulness in clinic. BMJ 2016;352:i13


THE BMJ’S WINTER APPEAL 2015

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(http://bmj.co/dotw) Ж Feature: Restoring Africa’s health systems

after Ebola (BMJ 2015;351:h6841)

“On the drive towards the Dunkirk camp, sleet and driving wind set an expectation of bleak, dire conditions. However, nothing could have prepared us for the suffering and despair we witnessed as we walked into the camp. Our path quickly became a sea of foul, ankle deep mud.

“Hundreds of tents were being buffeted by the strong wind, and many were lying flattened in the mud. We looked around: grim faced men, crying toddlers, everything wet and sodden.”

Two UK doctors saw the physical squalor and mental suffering in the camps at first hand

Read more on thebmj.com Ж BMJ 2015;351:h6924Registered charity number 1067406

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The new film Concussion tells the story of a naive young Nigerian pathologist who took on the multibillion dollar

National Football League (NFL) over its record on protecting players from brain injury.

Will Smith plays Bennet Omalu, a medical examiner in Pennsylvania, who first came up against the NFL in 2002 when he did an autopsy on “Iron Mike” Webster, a legendary Pittsburgh Steelers’ center for 15 years. Webster died at the age of 50 from a myocardial infarction, but Omalu wanted to find out what led to the player’s well documented meltdown after his retirement. He ended up living in his car and was confused, forgetful, and depressed.

When he examined Webster’s brain Omalu was surprised to find that it showed no obvious after effects from the many knocks and slams it would have received over a 15 year playing career. There was no sign of cortical atrophy, cortical contusion, haemorrhage, or infarcts. He examined the brain further and eventually found deposits of Tau proteins and neurofibrillary tangles and diagnosed the first case of chronic traumatic encephalopathy (CTE).

Omalu published his findings and diagnosis in the journal Neurosurgery in 2005, followed by another case study in 2006. Both times the NFL urged Omalu and his coauthors, who included eminent neurosurgeons, to retract.

Smith plays Omalu as an innocent abroad, a man puzzled that the NFL would dismiss the science. The risks of repeated concussion from players slamming heads were known long before Omalu became involved, but he was the first to diagnose CTE. The NFL had its own team of doctors looking at brain injuries and did not like this young upstart pointing out the flaws in their research.

The NFL calculates that 28% of players will have some form of brain disease

MEDICINE AND THE MEDIA

A doctor who took on the might of American footballAnne Gulland discusses a film that tells of the diagnosis of the first case of chronic traumatic encephalopathy

The film finishes with a statement about NFL’s concussion settlement with more than 5000 former players, agreed in April 2015. The NFL calculates that 28% of players will have some form of brain disease. However, the film does not point out that some players have refused the deal, saying that the range of diseases covered is too small.

Omalu is now a pathologist in California but continues his work on CTE with the Brain Injury Research Institute. With researchers at the University of California, Los Angeles, Omalu and Bailes have been working on scans to diagnose CTE before death because currently it can be confirmed only at autopsy. One of the people scanned was Fred McNeill, a linebacker with the Minnesota Vikings for 11 years, who developed dementia. He died in November at the age of 63 and the results of his autopsy are imminent, says Laskas.

The NFL has been talking about improving helmet design but Laskas describes this as the “filtered cigarette of the 21st century.”

“This is the discussion that America keeps not having. But what’s different this time is that there’s a Hollywood movie and the subject will be discussed in a way that people will understand,” she says.Anne Gulland is a freelance journalist, London [email protected] this as: BMJ 2016;352:h6856Find this at: http://dx.doi.org/10.1136/bmj.h6856

Actor Will Smith as the medical examiner Bennet Omalu

Omalu’s story might have remained untold if it were not for Jeanne Marie Laskas, a journalist at GQ magazine, who discovered him when writing an article about brain injuries among footballers.

David and GoliathIt’s a classic David and Goliath tale—the little guy against the multibillion dollar machine that is the NFL, says Laskas.

“It’s about the outsider who tries to take on big business. You have to think about how huge the NFL is. It’s bigger than Hollywood; it’s the behemoth of entertainment in America,” she says.

Just as Omalu received threats after he first published his research, Laskas also received hate mail from football fans accusing her of wanting to water down the game.

“I didn’t set out to indict the NFL. I just wanted to tell the inspiring story of a guy who found out something interesting,” she says.

In September Sony Pictures Entertainment was accused of making changes to the film to suit the NFL—an accusation that Laskas denies, telling detractors to wait until the film comes out. Unlike most major Hollywood studios, Sony has no significant ties to the NFL. And the film appears not to pull its punches, depicting NFL high ups as masters of obfuscation, obstructing Omalu and one of his supporters, neurosurgeon Julian Bailes, at every step.


Poor people and people with chronic diseases and disabilities are inevitably adversely affected by copaymentsno

All rich countries face rising healthcare costs as life expectancy increases, infant mortality falls, and more treatments emerge, regardless of whether they fund these costs by general taxation or through compulsory insurance schemes.21‑24 Extensive international empirical evidence shows that strong primary care led health systems, free at the point of access, are associated with improved outcomes, increased quality of care, decreased health inequalities, and lower overall healthcare costs.21 24

Copayments don’t workSome countries have tried to limit patient demand or reduce spending on healthcare by introducing copayments. This has resulted in increased health disparities with no change in patient demand.25‑28 Governments in these countries end up reimbursing, capping, and waiving the copayment to reduce health disparities.24

The overall costs of these remedial actions are not usually available. However, Germany introduced a fee for service copayment in 2004, which it scrapped in 2012. It cost the German government €360m (£260m) a year to run, and on average each year for every medical centre the scheme cost €4100 in administration and resulted in 120 hours of extra work.25 29

In other countries, for example, New Zealand and the Irish Republic, where patients have always made a copayment to GPs, it has interfered with initial access to care and deterred preventive care measures, resulting in greater health spending in secondary care.23 26‑ 28

Charges also have a detrimental effect on the doctor‑patient relationship. I have 15 years’ experience as a UK trained GP working in several different countries with different levels of copayment. Even in countries that never offered free consultations, many patients complained about fees or were unable to pay them for many reasons. Financial discussions could arise at any stage of the consultation and on a daily basis. This

can immediately change the dynamic and outcome of the consultation.

Copayments can deter doctors from asking patients to return for review or deter patients from meeting your request. They can deter patients from seeing the GP as advised after medical or surgical discharge from hospital. They can encourage patients to collect multiple problems to discuss in a single consultation and pressure doctors to deal with them all at once. And they can encourage unnecessary prescribing or referral—“I’ve paid, do as I say.”

Some practices may be tempted to deal with complaints from patients by offering a refund of the copayment rather than improve their service. They act as a financial deterrent and encourage deferring attendance until very unwell, with more likelihood of a need for hospital admission.

Copayments make no discernible difference to rates of non‑attendance and no difference to attendance rates of the worried well. Patients who cannot afford to see a GP simply attend free emergency departments.

Receptionists gain the additional work of collecting fees, and practices often have to use debt collection agencies.

Conflict of interestCopayments introduce a conflict of interest for GPs wanting to offer equitable and excellent standards of care to all their patients while protecting their income. Most UK GPs are self employed contractors working for a practice owner on a fee for service basis at around 55% of total fees.

Without patients there is no income. Apply discretion and don’t charge a copayment fee, then you subsidise the patient out of the practice’s and your own income. Poor people, mentally ill people, and people with chronic diseases and disabilities are inevitably adversely affected by copayments.

We should keep the NHS free for all at the point of access because it makes good economic sense, is better for healthcare outcomes, reduces bureaucracy, and allows for innovative ways to match supply and demand in general practice.Cite this as: BMJ 2016;352:h6800Find this at: http://dx.doi.org/10.1136/bmj.h6800

Nancy Loader is a GP partner, Beccles, Suffolk [email protected]

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Various calls have been made in recent years to charge patients for general practice consultations in the United Kingdom.1 2 In 2014 motions in favour of copayments were defeated at meetings of the BMA’s local medical committees3 and the Royal College of Nursing.4 In Australia, however, patients pay the doctor at the end of general practice consultations. No one sees this as unethical—it is the norm. The amount depends on the duration and complexity of the consultation and on the clinician but is typically about £10 for a standard consultation, with the remainder of the costs paid by the government.5

The NHS prides itself on free healthcare at the point of service, but with ever increasing demands, and its inflation adjusted annual budget rising over sevenfold from £15bn to £115bn in its 67 year history,6 we need fundamental change to ensure its prosperity and longevity.

Drug prescriptions and dentistryPeople in the UK already pay towards drug prescriptions and dentistry, which were free at the NHS’s inception,7 showing that the public accepts that an entirely free healthcare model is not sustainable today. Prescriptions, despite 90% of items being exempt from charges, generate in excess of £400m gross income a year.8

We should follow many other developed countries and also pay a fee when we see our GP. Given that the average patient visits their primary physician 5.5 times a year,9 a £10 fee, which most GPs would find acceptable,10 could raise billions of pounds. Vulnerable groups, including children and elderly people, would be exempt from charges as they are for existing prescription charges.

Charges may offer other benefits. These include a reduction in missed appointments, which are estimated to cost the NHS £162m a year.11 Charges have been shown to reduce missed reservations in other industries,12 13 and they might also encourage patients to take more personal responsibility, leading to fewer people attending with conditions that they could manage themselves or that would be better managed through other primary care services (pharmacists, dentists, nurses, etc). This would lead to greater service availability and shorter waiting times in general practice.

Although demographics differ, annual GP attendances per person in Australia (mean 5.6) are comparable with those in the UK,14 as are the number of emergency department attendances (mean 0.29/person/year in Australia v 0.33 in UK)15‑18 and life expectancy.19 This suggests that copayments are unlikely to affect care seeking behaviour or overall health. Any increase in use of secondary care to avoid fees could be countered by effective triage and redirection to an increased provision of hospital based GPs.

No superior alternativeIn a recent poll more than half of 440 GPs supported implementing charges for appointments.20 Copayments would not be a vote winning strategy for politicians, with healthcare unions and the public understandably against losing a free service.3 4 However, with billions of pounds of savings needed to keep the health service afloat, political popularity will be tough whatever the strategy.

To maintain the highest possible standards for all patients, amid ever increasing healthcare costs, we need radical measures to ensure the continued success of the NHS. If we could accept the morality of paying for consultations while ensuring strategies to protect vulnerable people, we could reap the benefits of a more prosperous and less strained healthcare system.

David Jones is a foundation year 2 doctor, diabetes and endocrinology, Worthing Hospital [email protected]

yes The argument that charges would deter sick people from seeking help doesn’t stand up

HEAD TO HEAD

Should patients pay to see the GP? Copayments could raise much needed funds for the NHS, thinks David Jones, but Nancy Loader worries about increased overall cost and harms to patients


In the late 18th century the British philosopher Jeremy Bentham proposed a design for a prison, the “panopticon,” in which a single watchman could

observe any of the inmates at any time. The fact that the inmates would not know who was being watched at any moment meant that they would act as though they were always being watched. The ideas behind Bentham’s panopticon have parallels with the constant scrutiny and observation to which doctors are now subjected, though the principle of central inspection, surveillance, and monitoring is becoming ubiquitous across UK society in the digital age.

Online healthcare rating websites such as PatientOpinion (www.patientopinion.org.uk), IWantGreatCare (www.iwantgreatcare.org), and NHS Choices (www.nhs.uk) allow patients to rate services and individual healthcare professionals, though currently few patients use them. A 2012 study in London reported that 15% of people were aware of doctor rating sites but that only 3% had used them. Similar rates of use have been reported in the United States, where more than 90% of the comments left are positive and there is little evidence of negative reviews.

You are being watched: panopticons in healthcareBen Wessely and Clare Gerada consider the effect on medical practice of online rating websites

FIVE FACTS ABOUT THE MEDICAL WORKFORCE IN 2016

1 GENDER MIX The proportion of women in

the medical workforce is rising, show data from the GMC’s latest “State of medical education and practice in the UK” report. Wom-en account for 57% of doctors in training, and 33% of specialists. Female GPs outnumber their male colleagues, accounting for 63% of GPs under 40, 56% of those aged 40-49, and 37% of those aged 50 and older.

2 ETHNICITY The pro-portion of doctors who are

graduates of UK medical schools and come from a black and mi-nority ethnic background (BME) has increased. UK BME doctors account for 17% of GPs and 15% of specialists. BME doctors who gained their medical qualifica-tion overseas made up 17% of the workforce, while BME doc-tors from the European Economic Area made up less than 1%.

3 DOCTORS FROM ABROAD Between

2011 and 2013, there was an increase in the number of doc-tors from Greece, Italy, Portugal, and Spain gaining a UK licence to practise. During the same pe-riod, there was a decrease in the number of UK licensed doctors from South Africa, by 478, and India, by 469. There were also fewer graduates from Nigeria and Sudan.

4 AGE GROUP Half of doctors (50%) in training

are aged between 20 and 29 and 45% are aged between 30 and 39. The remaining 5% of junior doctors were aged 40 or over. The majority of doctors (57%) with a licence to practise were aged between 30 and 49, and 27% were aged 50 and over. Doctors are now retiring earlier and the proportion of doctors aged 60 and over has fallen.

Patients do not restrict their comments to doctors’ technical skill

To understand doctors’ thoughts about websites that allow patients to rate them, one of the authors (BW) conducted group discussions, focus groups, and semi-structured qualitative interviews at a series of listening events for NHS staff in 2014 and 2015. Doctors at the events suggested that, despite their low popularity, these websites had great influence on doctors’ practice. They said that they feared that withholding non-evidenced or unnecessary treatment might mean disgruntled patients leaving negative comments.

The effect of rating websites on health professionals has also been examined in the United States. In a study of 155 doctors 78% reported that patient satisfaction surveys moderately or severely affected their job satisfaction. In addition, 28% had considered quitting their job or leaving the medical profession and 20% reported their employment being threatened as a result of patient satisfaction data.

The findings of the US survey also indicated that rating websites led to a change in clinical behaviour. Almost half of the respondents believed that pressure to obtain better scores promoted inappropriate care, including unnecessary prescriptions of antibiotics and opioids, tests,

procedures, and admissions to hospital. A third (34%) reported that they had unnecessarily admitted a patient to hospital because of patient satisfaction surveys, and 18% endorsed a procedure that they believed to be unnecessary. Research also indicates that patients report lower levels of satisfaction with general practices that have a cautious approach to antibiotic prescribing.

On rating websites patients do not restrict their comments to doctors’ technical skill or knowledge. They reflect on whether they had a “good emotional experience” and on doctors’ personality, empathy, politeness, and ability to listen. They also comment on car parking facilities, the comfort of the waiting room, waiting times, and the ease of obtaining an appointment. The websites mean that healthcare professionals are now potentially under constant observation,


FIVE FACTS ABOUT THE MEDICAL WORKFORCE IN 2016

5 SPECIALTY A quarter (25%) of

licensed doctors on the specialist register work in general medicine and 18% of doctors work in surgery. The proportion of doctors in each specialty had remained relatively stable, but the proportion working in public health, pathology, and occupational medicine has fallen.

Autopsy of an auditChristian Schopflin and colleagues implemented an audit that went “spectacularly” wrong. Here, they outline the reasons for the failure

The General Medical Council stipulates that “all doctors in clinical practice have a duty to participate in clinical audit.” But 56% of audits fail to achieve

change, and this may be an underestimate as failed projects often remain unreported.

We think three specific factors directly contributed to a spectacular audit project failure. These were staff sickness, poor stakeholder commitment, and leadership change. Awareness of these problems should help readers who may themselves be involved in service improvement work.

The audit evaluated whether preoperative investigations requested by nursing staff adhered to the National Institute for Health and Care Excellence guidelines. Results showed that 15% of investigations were unnecessary. We therefore introduced an app, which is freely available at www.preop.uk that auto selects appropriate investigations once baseline parameters have been chosen.

After a trial period of one month our re-audit showed that the app had been used in less than 3% of patients and performance had not improved. Reflecting on the project’s failure we identified three red flag signals that emerged during the implementation phase. These signals should have prompted a strategy review, and ignoring these warnings culminated in failure.

Staff sicknessWe thought that New Year might be a good time for departmental change. But higher than usual staff sickness levels meant that training sessions were poorly attended and raising awareness was difficult. The increased sickness absence in January reflects a wider pattern found within the NHS and nationally. On this basis we recommend spring and summer as favourable periods for change. But August may be disrupted by school holidays and new doctors starting work. Spring may therefore be the best time to implement new projects.

Stakeholder commitmentBefore introducing the app we consulted nurses, who expressed enthusiasm for

it. But training showed that the app did not represent a true one stop shop, and occasionally additional requests had to be made. This substantially dampened staff enthusiasm and staff became less keen to use the app. Research investigating the barriers to implementation of evidence based practice widely recognises the importance of staff attitudes and motivation. We think that staff disengagement with a proposed change is an absolute red flag that warrants urgent re-evaluation of the strategy. Failure to do so will undermine any project’s success.

Leadership changeDuring the implementation phase the chief nurse transferred the project leadership responsibilities to another staff member. The new leadership was well informed, but staffing levels became the department’s first priority. This diverted attention and project deadlines were missed.

We believe that leadership change is an important event that should trigger the following questions: Is this department ready for change? Are there more urgent priorities? Is the leadership truly committed to the proposed change? Does the leadership receive sufficient support?

Our project has been abandoned until further notice. Once the department is fully staffed we may revisit this project.

As healthcare professionals we are expected to participate in service development and leadership despite having little or no formal expertise in these areas. We hope that our experience will help others.Christian Schopflin is a year 7 specialist trainee, anaesthesia [email protected] Wigley is a year 1 core trainee, anaesthesiaAnthony Shepherdson is a year 1 core trainee, anaesthesia, Salisbury NHS Foundation TrustMatt Taylor is a year 4 specialist trainee, anaesthesia, University Hospital Southampton NHS Foundation Trust

extending beyond moments of formal observation.

If websites for rating healthcare professionals mean more compassionate or better care, then the panoptic model is surely not a bad thing. But rating websites may be damaging the care of patients by a move away from the provision of evidence based medicine or treatment, in patients’ best interests, towards acquiescence to patient demand.

Policies should focus on different methods of allowing patients to give constructive feedback, rather than promoting worry and even fear among staff and organisations.Ben Wessely is a MA student in social workClare Gerada is a general practitioner, London [email protected]

A panopticon, in which inmates are under constant scrutiny


BMJ CONFIDENTIAL

Anne MackieOptimistic and pragmatic

Anne Mackie is director of programmes for the UK National Screening Committee, an independent body hosted by Public Health England but that provides advice to all four UK nations. She has worked in public health for the past 20 years, including spells as director of public health in Kent, southwest London, and the London Strategic Health Authority. She is keen to emphasise that, although screening is not o� ered unless evidence shows that it will do more good than harm for the target group, it is an individual’s right to choose screening, and that depends on their being given sound, unbiased advice. “Finding stu� isn’t always a good thing,” she told the Times , while describing current tests for dementia as un� t.

What was your earliest ambition? To be a doctor (honestly), though I hope my understanding of what it means to be a doctor has moved on a bit since I was 11. Less pipes, wires, and answers, and more social, psychological, and mysteries. Who or what has been your biggest inspiration? London. I came in 1980 wide eyed at the mix of people, the excitement, ethnic food shops, and the fact that no one minded much what you did or looked like (within limits), and I still feel that every day. What was your best career move? Moving into national screening work. Very few public health jobs have such a clear link between research, guidance, and people living longer and healthier lives. For example, through work with literally thousands of clinicians, the NHS has one of the lowest rates of HIV transmission from mother to child in the world—an achievement of which we should all be justly proud. Where are or were you happiest? On a beach with my family, eating crab sandwiches, and waiting to swim. What single unheralded change has made the most difference in your field in your lifetime? Mobile telephony: millions of people worldwide can learn a little more about their and other people’s worlds, can access and spend money without bank accounts, and even get healthcare and advice across huge distances. More parochially, I can work while travelling between meetings. Do you support doctor assisted suicide? I do. I believe that people should decide what’s best for themselves and get help if they need it, though of course it needs to be carefully managed. What book should every doctor read? Foucault, Health and Medicine . It provides a way of thinking about prevention, health promotion, and the dominance of health and wellness as a modern preoccupation, and it really helped me to understand or at least analyse how health and wellness are used by policy makers. What is your guiltiest pleasure? A detective novel I can read in three hours. What television programmes do you like? I love the BBC self parody W1A , though it is so excruciatingly embarrassing and on the mark that I mostly have to watch from behind the sofa. We have nominated one of my team as “head of better.” What, if anything, are you doing to reduce your carbon footprint? I cycle everywhere. Though to be honest it’s because I’m too impatient and mildly claustrophobic to enjoy waiting for and travelling on buses or tubes. What personal ambition do you still have? To stay fit and positive and to enjoy my family, friends, and work. Summarise your personality in three words Optimistic, direct, and pragmatic. What is your pet hate? People telling me that cycling is unsafe. Cite this as: BMJ 2016;352:h6710 Find this at: http://dx.doi.org/10.1136/bmj.h6710

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